Precious Glimpse - Roundhay

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that the registered manager proactively collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. We found new breaches of regulations 12 and 17 and continuing breaches of regulation 17. This meant the service management was inconsistent. The registered manager and the culture they created did not support the delivery of high-quality, person-centred care.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

The evidence showed some shortfalls. Although the registered manager had a vision, based on provision of a bonding experience for families, they did not demonstrate a well-developed understanding of equality, diversity and human rights. They did not prioritise safe, high- quality care.

We requested but did not receive the provider’s equality and diversity policy, or training records to demonstrate the registered manager understood equality, diversity and human rights.

The registered manager could not demonstrate the service had a positive, listening culture. They did not promote trust and understanding between them and the women using the service, because they were not focused on learning and improvement.

The service’s vision of what it wanted to achieve, was to continue to offer souvenir 2D, 3D and 4D live HD scans, as a bonding experience for families.

The registered manager told us there were no long-term plans or strategies to expand or grow the business.

The evidence showed significant shortfalls. Although the registered manager understood the context in which the service delivered care, treatment and support, they did not demonstrate the skills and knowledge, to manage the service effectively. They did not show that they understood the impact their behaviours and management capability had on outcomes and experience.

The registered manager could not demonstrate they understood and managed the priorities and issues the service faced, or that they understood their responsibilities and legal duties regarding the Health and Social Care Act HSCA (Regulated Activities) Regulations 2014 and Registration Regulations 2009.

For example, we requested but did not receive an up-to-date Statement of Purpose for the service. The registered manager could not demonstrate they had taken any action to address regulatory breaches identified at our last inspection. In addition, the registered manager confirmed they had never displayed a CQC ratings poster following our inspection in 2019. We requested but did not receive photographic evidence that this was in place after our onsite visit.

Although requested, we did not receive any documentation or training records to demonstrate the registered manager had completed any continuing development.

The service did not engage with the assessment process and did not provide any requested data to inform this assessment.

The evidence showed significant shortfalls. People were not encouraged to speak up, so that their voice would be heard.

There were no feedback forms available in the waiting area for people to complete and share their experience of the service.

The registered manager told us they collected feedback through the social media page or by direct text message.

Although most of the feedback we saw online was positive, learning from complaints and feedback was not seen as an opportunity for improvement. For example, the registered manager could not give examples of how they incorporated learning into daily practice.

Where online feedback was not positive, we saw they responded dismissively and the feedback was not accepted as a means to improve.

The evidence showed some shortfalls. The service could not demonstrate how it valued diversity in their workforce.

We requested but did not receive the provider’s recruitment and equality and diversity policies. In addition, we requested but did not receive any equality and diversity training records. This meant the service could not demonstrate how its focus was always on those with protected characteristics under the Equality Act 2010 and those from excluded and marginalised groups.

However, the registered manager was sole employee of Precious Glimpse Roundhay, and they told us this would be the case for the foreseeable future.

The evidence showed significant shortfalls. The service did not demonstrate clear responsibilities, roles, systems of accountability and good governance. The registered manager did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The service did not operate effective governance systems and processes.

There were no up-to-date policies, scan protocols or current best practice guidance to refer to onsite.

Performance data was not collected and analysed. Areas for improvements were not identified or considered.

The registered manager did not conduct and document any audit activities, quality control or safety checks to monitor and maximise safety and quality of services, with a view to improvement.

The registered manager did not create and manage electronic and paper-based records in accordance with General Data Protection Regulation (GDPR) 2018. We requested but did not receive the provider’s policy for management of records. Data systems we saw onsite were not secure.

The registered manager confirmed the provider was not registered with the Information Commissioners Office, although they processed and stored people’s sensitive data for up to 5 years electronically and 3 years for paper records.

The registered manager could not demonstrate they had oversight of any risks we identified during our assessment. For example, risks associated with lack of current evidence-based policies and protocols, lone working, GDPR non-compliance, poor IPC, lack of housekeeping, inadequate equipment, lack of clinical risk assessments, and mitigation of any environmental risks.

In addition, although requested, the provider did not provide any documentation to demonstrate they held public liability indemnity insurance.

The service did not have any plans to cope with unexpected events and did not have a business continuity plan.

The evidence showed significant shortfalls. The registered manager did not understand their duty to collaborate and work in partnership, so services work seamlessly people. They did not share information and learning with partners or collaborate for improvement.

The registered manager told us they did not engage with the franchisor or seek any support or guidance from them. They did not collaborate with external stakeholders and agencies to improve care and treatment. For example, local advocacy and bereavement services, and they had no contact with any other baby scan services.

The registered manager did not openly engage with women and their families, equality groups, the public or local organisations, to plan and manage services.

However, they shared information with GPs and maternity services if women consented, although there was no policy regarding information sharing.

The evidence showed significant shortfalls. The service did not focus on continuous learning, innovation and improvement.

The service was unable to demonstrate it was committed to continually learning and improving.

There were no processes for learning when things went wrong or from good practice, either locally or nationally.

The registered manager did not demonstrate a good understanding of quality improvement methods.